20 so many and such ingenious plans for enabling him to acquire the maximum of knowledge within the minimum of time. Certainly there is no lack of such epitomes of the various parts of medical scier.c), and it may hardly seem necessary to have made any further additions to the series. We confess to a certain degree of old-fashioned prejudice against the free use of such aids to knowledge, believing that the student is better off with a good text-book and practical exercises than with an epitome of another’s making. But the fact is that the subjects have outgrown the limits within which they used to be sufficiently acquired, and the examination system is responsible for a great deal of the change that has come over the face of medical education. The student is coming to rely less and less upon his own resources, tutorial classes take the place of practical exercises, and the time-honoured method of lecture is fast dwindling in importance. The series of manuals to which the books named above belong stand to the student more in the position of the tutor rather than of the professor. Indeed, all but one of these " Essentials" is planned on the style of " Sandford and Merton" or the " Guide to Know- ledge,"a questionbeing propounded and its answer appended. There is not much room for independent thinking or the cultivation of the higher mental faculties in such exercises as these ; but yet we do not doubt that, under the present condition of things, there is probably a considerable demand for literature of this sort. It is fortunate for the student that these books should be undertaken by competent hands—by men who, being themselves engaged in teaching, know where the subjects require most elucidation, and who, moreover, are careful to be accurate in their state- ments. We certainly cencur with the remark by Dr. H. A. Hare, the author of the " Physiology Essentials," to the effect that " a manual of this character is in no one way intended to supplant any of the text-books"; but in pro- portion as this class of work is accurate and careful, the greater is the risk of its being solely depended upon by the student, to the exclusion 0f works of wider scope. We do not want our medical men to be trained up on the mechanical plan of the village school, but we desire to see every means employed to awaken their powers of observation and thinking. Although, owing to their general scheme, there could hardly be much added to these works, yet they must be considered rather as useful adjuncts to systematic reading than as sufficient in themselves to impart the neces- sary knowledge of the subjects with which they deal. OUR LIBRARY TABLE. ,5cleet Methods in tlte Administration of Nitrous Owide and L’tlzer. By F. HEWITT, M.A., M.D. Cantab. Pp. 48. London: Dai1lière, Tindall, and Cox. The professed object of this little book is to explain certain methods whereby ether can be administered in combination with, or in succession to, nitrous oxide gas. With the excep- tion of an account of Dr. Hewitt’s modification of Mr. Clover’s well-known portable regulating ether inhaler, the apparatus described and the methods detailed are familiar to those who have read the general manuals dealing with anaesthetics. The descriptions are in some cases less clearly expressed than is desirable, and teud to over- elaborate a simple subject. There seems to be a pretty general feeling existing at the present time that if we employ ether in every-day practice, it is necessary to overcome its nauseous smell and deliriant properties by an initial administration of nitrous oxide gas. For surgical anesthesia this has been accomplished for many years with more or less success, and by the employment of very simple apparatus, so that we cannot welcome any change which increases their complexity by multiplying stopcocks, movable bags, and so on. An additional drawback involved in Dr. Hewitt’s arrangement exists in the fact that he advises the administrator to allow the patient to breathe the remainder (one gallon of nitrous oxide) backwards and forwards" (p. 1:3). This re-breathing of once respired gases is not only most disagreeable to the patient, but is actually deleterious. The apparatus Dr. Hewitt recommends possesses certain disadvantages: it is made in pieces, and so, even when as carefully constructed art the author very properly points out should be the case, it is liable to work loose and permit of ether leakage; there is also a fear of its component parts separating. Besides these drawbacks, it must necessarily be held in the hand, even when momentarily removed from the face. Dr. Hewitt appears not to be familiar with an older apparatus designed by Mr. Clover, for lie says: "By filling and detaching the gas-bag before the administration commences—a proceeding which is impossible in other methods-the patient is not frightened by the noise made by nitrous oxide issuing from the gas-bottles." In the older and simpler scheme, the gas-bag may be filled, a stopcock turned, and the gas apparatus detached; the patient then only sees the face- piece, and without the smell of ether can be rendered un- conscious. This apparatus (Clover’s) hangs suspended from the waistcoat button, and can be kept out of sight with the coat. Nor is it a necessity for noise to result from the gas leaving the bottle and entering the bag, unless it be permitted to tlow too rapidly. Another method now com- monly in use, but which Dr. Hewitt has not noticed, is to have a stopcock fixed in the metal knee-piece which connects the dome of Clover’s portable ether inhaler to the bag. To this is attached an indiarnbber tube, and through it the gas is allowed to enter. The method of using this contrivance is practically the same as that for Dr. Hewitt’s, only fewer valves and stopcocks are required. We must altogether dissent from Dr. Hewitt when (p. 33) lie says it is better in some cases to administer ether from a cone or towel rather than from a Clover’s inhaler. Any competent person accustomed to that instrument can regulate to a nicety the amount of ether given, and can allow any pro- portion of air to be admitted. With a cone this is im- possible ; nor can the administrator avoid a sudden increase in the strength of the ether vapour, which must induce suffocative cough and struggling, both undesirable com- plications in cases of strangulated hernia, severe hæmor- rhage, and obesity, the cases in which Dr. Hewitt advises its use. The book is well printed, and contains some excellent woodcuts illustrating Dr. Hewitt’s apparatus and mode of using it. On Syphilitic Affections of the Nerrous Systent; their Diagnosis and Treatment. By T. MCCALL ANDERSON, M.D. Glasgow : J. Maclehose and Sons. 1889.-This is eminently a clinical work. It consists in the records of twenty-four Cases of syphilitic nervous disease selected from the prac- tice of the author to illustrate most of the various forms in which such disease is manifested. Professor McCall Anderson quite agrees with those who regard syphilitic nerve disease as being common, and also as being most variable in its appearance as well as in its manifestations. In the concluding pages of the essay he sums up certain points in the diagnosis and treatment of such cases, which are well worthy the attention of practical physicians. It is interesting to learn that among thirteen of the twenty-four cases described, in which the time of syphilitic infection was known, the interval elapsing between that date and the onset of nervous symptoms varied from two years and a half to thirty years. The author is an advocate of the use of mercury, which lie prefers to administer by inunction or by subcutaneous injection, although lie admits that in many cases iodide of potassium is all-sutllcient. The brochure is supplemented by a full report of the discussion which followed upon Professor McCall Anderson’S remarks on this
Transcript
20
so many and such ingenious plans for enabling him toacquire the maximum of knowledge within the minimum oftime. Certainly there is no lack of such epitomes of thevarious parts of medical scier.c), and it may hardly seemnecessary to have made any further additions to the series.We confess to a certain degree of old-fashioned prejudiceagainst the free use of such aids to knowledge, believingthat the student is better off with a good text-book andpractical exercises than with an epitome of another’s
making. But the fact is that the subjects have outgrownthe limits within which they used to be sufficiently acquired,and the examination system is responsible for a great dealof the change that has come over the face of medicaleducation. The student is coming to rely less and lessupon his own resources, tutorial classes take the place ofpractical exercises, and the time-honoured method of lectureis fast dwindling in importance. The series of manuals towhich the books named above belong stand to the studentmore in the position of the tutor rather than of the professor.Indeed, all but one of these " Essentials" is planned on thestyle of " Sandford and Merton" or the " Guide to Know-ledge,"a questionbeing propounded and its answer appended.There is not much room for independent thinking or thecultivation of the higher mental faculties in such exercisesas these ; but yet we do not doubt that, under the presentcondition of things, there is probably a considerable demandfor literature of this sort. It is fortunate for the studentthat these books should be undertaken by competenthands—by men who, being themselves engaged in teaching,know where the subjects require most elucidation, andwho, moreover, are careful to be accurate in their state-ments. We certainly cencur with the remark by Dr. H.A. Hare, the author of the " Physiology Essentials," to the effect that " a manual of this character is in no one wayintended to supplant any of the text-books"; but in pro-portion as this class of work is accurate and careful, thegreater is the risk of its being solely depended upon by thestudent, to the exclusion 0f works of wider scope. We donot want our medical men to be trained up on the mechanical plan of the village school, but we desire to seeevery means employed to awaken their powers of observationand thinking. Although, owing to their general scheme,there could hardly be much added to these works, yet they must be considered rather as useful adjuncts to systematicreading than as sufficient in themselves to impart the neces-sary knowledge of the subjects with which they deal.
OUR LIBRARY TABLE.,5cleet Methods in tlte Administration of Nitrous Owide
and L’tlzer. By F. HEWITT, M.A., M.D. Cantab. Pp. 48.London: Dai1lière, Tindall, and Cox. - The professedobject of this little book is to explain certain methodswhereby ether can be administered in combination with,or in succession to, nitrous oxide gas. With the excep-tion of an account of Dr. Hewitt’s modification of Mr.
Clover’s well-known portable regulating ether inhaler,the apparatus described and the methods detailed arefamiliar to those who have read the general manualsdealing with anaesthetics. The descriptions are in somecases less clearly expressed than is desirable, and teud to over-elaborate a simple subject. There seems to be a pretty generalfeeling existing at the present time that if we employ etherin every-day practice, it is necessary to overcome its nauseoussmell and deliriant properties by an initial administrationof nitrous oxide gas. For surgical anesthesia this has beenaccomplished for many years with more or less success, andby the employment of very simple apparatus, so that wecannot welcome any change which increases their complexityby multiplying stopcocks, movable bags, and so on. Anadditional drawback involved in Dr. Hewitt’s arrangement
exists in the fact that he advises the administrator to allowthe patient to breathe the remainder (one gallon of nitrousoxide) backwards and forwards" (p. 1:3). This re-breathingof once respired gases is not only most disagreeable to thepatient, but is actually deleterious. The apparatus Dr. Hewittrecommends possesses certain disadvantages: it is made inpieces, and so, even when as carefully constructed art theauthor very properly points out should be the case, it isliable to work loose and permit of ether leakage; there isalso a fear of its component parts separating. Besidesthese drawbacks, it must necessarily be held in the hand,even when momentarily removed from the face. Dr. Hewittappears not to be familiar with an older apparatus designedby Mr. Clover, for lie says: "By filling and detaching thegas-bag before the administration commences—a proceedingwhich is impossible in other methods-the patient is notfrightened by the noise made by nitrous oxide issuing fromthe gas-bottles." In the older and simpler scheme, the
gas-bag may be filled, a stopcock turned, and the gasapparatus detached; the patient then only sees the face-piece, and without the smell of ether can be rendered un-conscious. This apparatus (Clover’s) hangs suspended fromthe waistcoat button, and can be kept out of sight withthe coat. Nor is it a necessity for noise to result fromthe gas leaving the bottle and entering the bag, unless it bepermitted to tlow too rapidly. Another method now com-
monly in use, but which Dr. Hewitt has not noticed, is tohave a stopcock fixed in the metal knee-piece whichconnects the dome of Clover’s portable ether inhaler to thebag. To this is attached an indiarnbber tube, and throughit the gas is allowed to enter. The method of using thiscontrivance is practically the same as that for Dr. Hewitt’s,only fewer valves and stopcocks are required. We mustaltogether dissent from Dr. Hewitt when (p. 33) lie says itis better in some cases to administer ether from a cone ortowel rather than from a Clover’s inhaler. Any competentperson accustomed to that instrument can regulate to anicety the amount of ether given, and can allow any pro-portion of air to be admitted. With a cone this is im-
possible ; nor can the administrator avoid a sudden increasein the strength of the ether vapour, which must inducesuffocative cough and struggling, both undesirable com-plications in cases of strangulated hernia, severe hæmor-
rhage, and obesity, the cases in which Dr. Hewitt advisesits use. The book is well printed, and contains someexcellent woodcuts illustrating Dr. Hewitt’s apparatus andmode of using it.On Syphilitic Affections of the Nerrous Systent; their
Diagnosis and Treatment. By T. MCCALL ANDERSON, M.D.Glasgow : J. Maclehose and Sons. 1889.-This is eminentlya clinical work. It consists in the records of twenty-fourCases of syphilitic nervous disease selected from the prac-tice of the author to illustrate most of the various formsin which such disease is manifested. Professor McCall
Anderson quite agrees with those who regard syphiliticnerve disease as being common, and also as being mostvariable in its appearance as well as in its manifestations.In the concluding pages of the essay he sums up certainpoints in the diagnosis and treatment of such cases, whichare well worthy the attention of practical physicians. It is
interesting to learn that among thirteen of the twenty-fourcases described, in which the time of syphilitic infectionwas known, the interval elapsing between that date andthe onset of nervous symptoms varied from two years anda half to thirty years. The author is an advocate of theuse of mercury, which lie prefers to administer by inunctionor by subcutaneous injection, although lie admits that inmany cases iodide of potassium is all-sutllcient. The brochureis supplemented by a full report of the discussion whichfollowed upon Professor McCall Anderson’S remarks on this
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subject at the Glasgow meeting of the British MedicalAssociation.
Mikrophotographischer Atlas der Bakterienkunde. VonDr. CARL FRAENKEL und Dr. RICHARD PFEIFFER. Ersteund zweite Lieferung. Berlin: A. Hirschwald. 1889.-The application of photography to microscopical researchhas been in no department better illustrated than with
respect to bacteriology. In this country Prof. Crookshankhas published a volume containing many successful micro-photographs of bacteria, and the work before us forms the.commencement of an Atlas having the same object in view.Its authors are well known as assistants in the HygienicInstitute at Berlin, of which Dr. R. Koch is the director, andto him the work is dedicated. In an introductory chapteriull details are given with regard to the methods employed;and there are ten plates, each containing two photographsaof various forms of micrococci, bacilli, and spirilla. The
plates are excellent examples of the art of microphotography,the definition of even the minutest forms (e.g., Fig. 12,minute spirilla in the blood of the monse) being very suc-cessfully obtained. By such works as this the morphologyof bacteria is -well illustrated, and the extent to which
bacteriology has been studied is brought home to those whomay have failed hitherto to grasp the fact, whilst to thosewho are actually engaged in the pursuit the possession of;such an Atlas must prove invaluable.
What shall we have for Brcakfast ? or Everybody’sBreakfast-book. By AGNES C. MAITLAND. Pp. 120.London : John Hogg. 1889.-This book is remarkablywell fitted to relieve the monotony and add to the enjoy-ment of the breakfast-table. It contains 181 recipes, whichhave the great merit of being described in plain intelligiblelanguage, and having the quantities of the various ingredientsclearly stated. They are within the compass of a fairly good<cook, and bear the impress of having been written by aperson who had actually put them in practice. It is a bookin every respect to be commended.
Puddings and Pastry à la mode. By Mrs. DE SALTS.Pp. 70. Cakes and Confections e’a la mode. By Mrs. DE SALTS.Pp. 61. London: Longmans. 1889. -These two little’volumes complete Mrs. De Salis’s à la mode series ofcookery-books. They contain recipes for some very de- ’,dicious and palatable articles, but are open to the sameobjection as some of the previous volumes--disregard of- expense, and the need of a first-rate cook to carry out someof them. They will be found useful by those who have.good artistes and to whom expense is no object.
HEALTH REPORT OF INDIA FOR 1887.
No. III.
THE returns of the births and deaths in the civil population-are so defective that we shall not go into detail in their con-sideration. In some of the provinces an attempt has beensnade to obtain more accurate figures, but apparently inmany of them without success. The ratio of mortality as:stated in the appendix has ranged between 16’18 in LowerBurma and 45’30 in Berar. In all of the provinces exceptBerar and Coorg, the town mortality is shown to have been’higher than in the rural circles, but we are disposed tothink very little reliance can be placed on the returns. For
-instance, in Lower Burma the death-rate of the towns is- stated to be 27’17, while that of the rural districts is only14’72. Fevers were reported as the cause of the greatestamount of deaths throughout India, contributing apparentlyabout two-thirds of the whole. Cholera appears to havecaused a high death-rate in Berar, 5 ’5 per 1000 ; in the North-West Provinces and Oudh, 4-54 per 1000; and in Bengal,proper, 2’60 per 1000. In none of the other provinces doesit seem to have reached 2 per 1000, at least so far as thedeaths were reported, and in most of these the ratio wasunder the average of the five preceding years. The monthsin which the deaths by cholera were highest were June,
July, and August; and those in which they were lowestwere February, November, and March. The death-rate bycholera in the town of Calcutta in 18a7 was 2’76 per 1000 ;among the seamen in the port, whose deaths are not in-cluded in this, the ratio was as high as 10’03 per 1000. Anumber of details are given showing the beneficial effects ofremoving soldiers from their barracks and prisoners from thegaols into camp on the outbreak of this disease. It wasoccasionally found necessary to move the camp before thedisease ceased, but in a large number of instances the firstchange seemed to secure immunity. In an interesting" Memorandum on Cholera as a Preventable Disease,"Surgeon-Major Hutcheson, the officiating statistical officerto the Government of India in the sanitary and medicaldepartments, has given a summary of the mortality fromthat disease of the European and Native troops of theBengal Presidency and in the gaols of Bengal for the thirtyyears 1858-87. The death-rate from cholera during thefirst fifteen years of that period compared with the lastfifteen was, among the European troops, 8’27 and 3’01;among the Native troops, 2’57 and 1’34 ; and in the gaols,7’94 and 3’27. Dr. Hutcheson remarks " that this lesseningmortality is real, and not a mere statement based on in-accurate statistics, and the manipulation of figures is provedby the gradual diminishing number of deaths year by yearfrom this cause in all the important stations of the BengalPresidency and among communities regarding whom thevital statistics are as accurate as any other community inthe civilised world." This reduction in the mortality hasbeen experienced in all the principal stations of Bengal.Diagrams are given illustrating this for several of themost important, and tables showing the deaths per1000 at each of the stations during the two periods offifteen years respectively. Similar tables are given show-ing the reduction in the cholera death-rate in the gaols.It is impossible to make any accurate comparison of thedeath-rate from cholera of these special groups and thegeneral population, as owing to the defective registration ofdeaths " even an approximate to the actual mortality fromcholera is not indicated by the record." But a glance atthe table of annual deaths from cholera in India from 1875to 1887, imperfect as it is, shows that there has been nosuch gradual reduction in the death-rate among the generalpopulation as among the three specially protected classes.In Bengal it was higher in 1887 than in nine of the precedingtwelve years ; in the North-West Provinces and Oudh itwas more than thrice as high as in any of the twelveyears except 1882, and more than twice as high as inthat year; and in all the other provinces except the Centraland Lower Burma it was very much in excess of the pre-ceding year. " The enormous totals, representing deathsfrom a preventable disease and one single cause are
sufficiently striking." We agree with Dr. Hutchesonin his conclusion that " the incidence of disease is greatlyless in all more or less protected communities than itwas, and that the average mortality from cholera wascent. per cent. more during the fifteen years ante-cedent to 1873 than it has been during the more recentperiod....... Again, where local sanitary protection isgreatest and palpable sanitary defects are fewest, there theimprovement, as shown, is marked by the enormous totalof 1300 per cent. greater mortality in former as comparedwith later years." From a consideration of all the pointsconnected with the prevalence of cholera in India, Surgeon-General Sir B. Simpson, the Sanitary Commissioner withthe Government, arrives at the conclusion, "that it is toimprovement in local sanitation, and not to the enforcementof quarantine regulations, that we must look as a means ofpreventing the occurrence of spreading epidemics."In an appendix to the report is a reprint of a resolution
of the Government of India in the Home Department onthe application of sanitary principles to towns and villagesin India. This directs the formation of a sanitary board inevery province, "not only as a consultative body, but alsoas the executive agency through which the Governmentacts in the sanitary department." The Government of Indiaseems to be alive to the difficulties of introducing and carry-ing out sanitary improvements involving expenditure bylocal authorities, and it will doubtless be a work of con-siderable time to develop an efficient system; but the stepswhich have been taken are in the right direction, and, ifjudiciously carried out, will doubtless be the means ofreducing the high rate of preventablemortality, and improvingthe health, comfort, and well-being of the general population.
